Free article: What makes a service safe?

Published: Tuesday, 16 December 2014

Martin Hodgson looks at the CQC’s key question ‘Is it safe?’


  • Asking if services are ‘safe’ is one of the new key questions introduced by the Care Quality Commission (CQC) into their inspection regime.
  • Inspectors will use so-called key lines of enquiry (KLOE) to answer the five key questions and to inform their judgements about the ‘safety’ of a service.
  • CQC guidance for adult social care, both residential care and domiciliary care, states that ‘safe care’ includes protecting service users from abuse and avoidable harm.
  • In adult social care, ‘safety’ also includes people being supported to make choices and take risks.

The new inspection system

Since October 2014 Care Quality Commission (CQC) inspectors have been implementing a new inspection model. This involves each provider being given a quality rating based on five key questions about the service:

  • Is it safe?
  • Is it caring?
  • Is it effective?
  • Is it responsive?
  • Is it well-led?

Quality ratings will state whether the care provided is outstanding, good, requires improvement or is inadequate.

An overall rating will be built up from the ratings for each of the five key questions. It will be published on the CQC website so that the public can easily tell how good a service is and whether there are any problems with it.

Safety is seen by many as the most fundamental question in this assessment. Examples of services that have proved unsafe, such as Winterbourne View and the Mid-Staffordshire NHS Foundation Trust, have been far too numerous over the past few years. These have dented public confidence in health and care providers. The public demands services that are, above all, safe to use and free from abuse.

How will inspectors decide if a service is safe?

‘Safety’ is a very wide area where health and social care is concerned. All other aspects of care and the running of services link with safety or contribute to safety, especially aspects of leadership, risk management, training and staffing, health and safety, and quality monitoring and assurance.

So where will inspectors start in assessing the safety of a service?

According to the new model outlined by the CQC, inspectors will use a variety of methods to decide to what extent a service is ‘safe’.

The CQC’s strategy document, A fresh start, and the provider handbooks recently published for each care sector, all provide guidance on applying the five key questions in practice.

In the handbooks for residential social care and for domiciliary care the CQC states that asking if services are safe will involve inspectors checking that:

  • service users are supported to make choices and take risks
  • service users are protected from physical, psychological and emotional harm, abuse, discrimination and neglect.

For example, asking if services are safe may include inspectors checking whether:

  • medicines are managed properly
  • equipment is safe to use
  • infection control risks are managed
  • service users are supported adequately by staff, particularly those in need of safeguarding
  • providers learn from safety incidents.

With respect to adult residential social care, inspectors will also look at whether or not premises are clean and safe.

Making judgements

The new inspection regime will be characterised by a range of inspection methods, including face-to-face inspections by expert inspectors and local information gathered about providers. Those conducting inspections will look at whether the service complies with the law.

Until April 2015 inspectors will continue to use the existing regulations, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, and the standards and judgements set out in the CQC's Guidance about compliance: essential standards of quality and safety.

After April 2015, the CQC will use the new Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 which are currently passing through Parliament. The Regulations introduce new fundamental standards of care which will replace the outgoing essential standards.

Informed by both the current and the incoming regulations, and by established models of good practice, inspectors will use so-called key lines of enquiry to answer the five key questions.

Key lines of enquiry – KLOE

Key lines of enquiry (KLOE) consist of a series of questions provided by the CQC for inspectors to inform their judgements and support the five key question test.

KLOE help to describe what a good service looks like in the context of each of the five questions. However, the CQC states clearly that KLOE do not represent an exhaustive list of characteristics and should not be used as a checklist. They are intended to be applied using the profes-sional judgement of the inspection team taking into account best practice and recognised guidelines. The CQC also suggests that inspectors can develop their own lists and prompts of ‘good’ practice in order to inform their judgements.

Earlier this year the CQC published draft KLOE for consultation. Final versions have now been published for each regulated health and social care sector as appendices to the provider handbooks, available from the CQC website.

Service providers need to examine their services and check that they comply with the appropriate regulations and take note of the KLOE that relate to them.
So what do the finished KLOE advise inspectors to look for with respect to the safety of a care home or of a domiciliary care service?

Inspections based on how safe services are

The following mandatory categories are included in the most recent KLOE updates to inform inspectors’ judgements about how safe residential and community services and adult social care services are:

  • S1: How are people protected from bullying, harassment, avoidable harm and abuse that may breach their human rights?
  • S2: How are risks to individuals and the service managed so that people are protected and their freedom is supported and respected?
  • S3: How does the service make sure that there are sufficient numbers of suitable staff to keep people safe and meet their needs?
  • S4: How are people’s medicines managed so that they receive them safely?

Non-mandatory questions include:

  • S5: How well are people protected by the prevention and control of infection?

The questions are subdivided into a number of subsidiary questions. Each is linked to a range of potential evidence that acts as a prompt for inspectors. For example, in care homes S1 is sub-divided into the following questions related to abuse:

  • How are people protected from abuse and avoidable harm, including breaches of their dignity and respect, which can result in psychological harm?
  • How are people protected from discrimination, which might amount to discriminatory abuse or cause psychological harm?
  • Are people kept safe by staff who can recognise signs of potential abuse and know what to do when safeguarding concerns are raised?
  • How are people supported to understand what keeping safe means, and how are they encouraged to raise any concerns they may have about this?

The guidance suggests that inspectors ask service users if they feel safe and if they feel they are discriminated against.

Inspectors are advised to:

  • look for how staff interact with people
  • see if people’s dignity, identity etc. may be compromised
  • observe how staff support people whose behaviour challenges, for example people living with dementia
  • ask staff how they keep people safe and avoid discrimination and whether they have had any training on equality and diversity and the safe use of restraint
  • look at risk assessments and individual care records, including safeguarding records, accident and incident reports, quality assurance audits for safety, etc.

Characteristics of ‘good’ services

As well as the lists of KLOE questions, prompts and suggested sources of evidence, the provider handbooks also contain a description of what services would look like at each level. Thus inspectors are provided with a snapshot of what an outstanding, good, poor or inadequate service looks like in practice.

The characteristics that the CQC sees as ‘good’ in terms of safety for both domiciliary care services and care homes include:

  • People’s feedback about the safety of the service describes it as consistently good and they ‘feel safe’.
  • People are safe because the service ‘protects them from bullying, harassment, avoidable harm and potential abuse’.
  • Staff have ‘a comprehensive awareness’ and understanding of potential abuse which helps to make sure they can recognise cases of abuse.
  • The service has a proactive approach to respecting people’s human rights and diversity and this prevents discrimination.
  • There are policies and procedures for managing risk and staff understand and consistently follow them.
  • Restrictions are minimised so that people feel safe but also have the most freedom possible – regardless of disability or other needs.
  • Staff give people information about risks and actively support them in their choices so they have as much control and independence as possible.
  • Staff manage medicines consistently and safely.
  • Where the service is responsible for equipment, it keeps it serviced and well maintained.
  • The service manages the control and prevention of infection well.
  • There are always enough competent staff on duty who have the right mix of skills to make sure that practice is safe and unforeseen events can be responded to.
  • The management identifies risks to the service and manages them well.
  • The service takes all possible action to reduce the risk of injury caused by the environment people live in, and looks for ways to improve safety.

In addition, a ‘good’ characteristic specifically for care homes is that premises are kept safe and well maintained. In domiciliary care services, inspectors are prompted to look for evidence that there are arrangements to deal with situations where carers cannot make visits due to ur-gent unexpected demand.

Further information

About the author

Martin Hodgson MSc, PGCEA is a community psychiatric nurse by background, and has had a long career working as a senior manager in various health agencies, including mental health, primary and community care.

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